Roger C. Green, maintenance specialist, age 44, was fatally injured
at approximately 10:00 a.m., on June 25, 1997, when he fell down an
elevator shaft in the preheater tower. The victim had a total of
15 years and 25 weeks of mining experience, all at this operation.

The company informed the investigators that Green had received
training in the use of fall protection and safety harness and
lanyard use. There was no record indicating that he had received
training in accordance with Part 48.

G. Duane Crutchfield, plant manager, notified MSHA of the accident
by phone at 12:50 p.m., on June 25, 1997. An investigation was
started the same day.

The Leamington Plant, owned and operated by Ash Grove Cement
Company, was located in Leamington, Juab County, Utah. Limestone
was quarried from four ridges in the mountain above the plant.
Silica, alumina, and iron were brought to the plant from outside
sources. The raw materials were crushed, milled, heated, and
processed to form cement. The finished product was distributed to
construction and manufacturing clients throughout the Intermountain
West.

Total employment at the operation was 85 persons working three, 8
hour production shifts per day, 7 days a week. The maintenance
department worked two, 8 hour shifts per day, 5 days a week. The
last regular MSHA inspection was completed on October 17, 1996.

PHYSICAL FACTORS INVOLVED

The accident occurred in the elevator shaft located in the 210-foot
high preheater tower. The shaft was 74 inches by 102 inches. The
elevator compartment was 66 inches by 76 inches and was 86 inches
high. The tower had ten floors that were accessible by stairs or
the passenger elevator.

Involved in the accident was a Model 430H, 2,000 pound capacity,
Viola elevator. The elevator had two doors, one outer door on each
floor and an inner door on the passenger compartment. The outer
doors had an electro-mechanical interlock which prevented them from
opening unless the elevator was in position at the floor. The
elevator would not move unless the inner door was securely closed.

The outer door interlock could be by-passed for maintenance and
repair to the elevator shaft or passenger compartment by inserting
a key in a slot on the upper left side of the door. Use of the key
allowed the outer doors to be opened irrespective of the location
of the passenger compartment. The manufacturer recommended that the
key be made available only to authorized personnel.

Rank-and-file employees stated that they routinely by-passed the
outer door interlocking mechanism by using welding rods with a hook
formed on one end. This allowed them to open the outer doors to
check on the location of the passenger compartment. Additionally,
a miner stated that in 1991, he opened the outer door to the
elevator shaft on the 4th floor and fell about 10 feet because the
passenger compartment had not leveled to that floor. No safety
belts or harnesses were used while engaging in this practice, and
employees stated that they held onto the tower's handrails or the
door frame to prevent falling into the shaft. Two company foreman
were aware of this activity and did not stop it. None of the
floors were equipped with structures or mechanisms on which safety
lines or lanyards could be secured. The falling hazard could be
from a few feet to about 200 feet dependent on the location of the
passenger compartment.

The elevator shaft doors were 34-1/2 inches wide and 83 inches
high. The doors opened into the travelway of the tower. A
hydraulic door closer was installed on each door to prevent them
from closing too fast. A number of the door closers were leaking
oil. A performance test of the door closers on all ten floors was
conducted. The doors were opened to 90 degrees and allowed to
close. The doors on all floors closed between 2 and 4.5 seconds.

During this inspection, it was discovered that the fourth floor's
outer door interlock system was defective. This defect allowed the
door to be opened without using a key to disable the mechanical
interlock. A citation was issued on a miscellaneous inspection, as
the defect did not contribute to the accident.

Maintenance personnel, including the victim, were assigned to
inspect and maintain the elevator. Computer generated check lists
were used to document defects and record repairs and maintenance.
According to the sheets, preventive maintenance was conducted on a
monthly, quarterly, or yearly basis, depending on what was
required. The preventive maintenance personnel were instructed to
complete the sheet, note any deficiencies, and return them to their
foreman. If defects were noted during those inspections, the
foreman determined if they warranted repair by company mechanics or
electricians. After that determination, the sheets were returned
to the planning department for final disposition.

The elevator was last certified for passenger use by the State of
Utah on May 14, 1997. It was last serviced by personnel from
Thyssen Elevator Company on June 23, 1997, at which time the
safeties were reset. No defects affecting safety were noted.
After the accident, all mechanical and electrical systems on the
preheater tower elevator were examined and tested. The tests
revealed that there were no defects in the elevator's mechanical or
electrical systems other than the previously noted defective shaft
door interlock on the fourth floor.

The victim carried a hand-held radio which enabled him to contact
his supervisor or other plant personnel. It was tested and found
to be operable.

There were no outside walls on the preheater tower, thus it was
exposed to the elements except where piping and other components of
the tower blocked some of the wind. Conversely, the elevator shaft
was fully enclosed. One miner described the wind on the day of the
accident as "blowing hard".

There were no witnesses to the accident. The top of the passenger
compartment was damaged at the location where the victim was found.
Scratches and other marks were found inside the elevator shaft
just below the ninth floor of the shaft. The victim had abrasions
on his fingers and a scuff mark on one of his boots.

DESCRIPTION OF ACCIDENT

Roger Green reported for work at 7:00 a.m., his normal starting
time. He was assigned to perform a preventive maintenance
inspection of the preheater tower and coal areas. He was observed
by coworkers working in various areas of the tower during the early
hours of the shift.

At about 10:15 a.m., Phil Halden, Fuller Company, tried to use the
elevator to access the tower's fourth floor to check ductwork
temperatures and fly dampers. The elevator did not respond when he
pushed the button. He used the stairway and completed his tasks.
At about 11:00 a.m., Adrian Beal, production assistant, went to the
tower to conduct various duties. Arriving at the first floor, he
called for the elevator by pushing the button but received no
response. Beal saw that there was no operating light nor bell
noise being generated by the elevator. He walked up the stairway
to the fourth floor and en route, stopped at each floor and called
the elevator but did not receive a response. He arrived at the
fourth floor and accomplished his task. Curious at the elevator's
failure to respond to his calls, he walked up the stairway to
investigate.

When Beal got to the sixth floor, he opened the outer shaft door
by defeating the interlock with a welding rod and saw the
passenger compartment several feet above him. He was not using a
safety belt or lanyard during this activity. At approximately
11:30 a.m., he walked up to the seventh floor and again used a
welding rod to open the outer door. He saw the victim on top of
the elevator passenger compartment between the 6th and 7th floors.

Beal called to Green but received no response. He radioed his
supervisor and informed him of the situation. Maintenance
specialist, Cory Frampton, an emergency medical technician (EMT),
arrived within a few minutes of Beal's radio call. Frampton
climbed into the shaft to assist the victim. Frampton was soon
joined by electricians, James Rasch and Bart Walker, one an EMT and
the other a first responder.

They checked for vital signs and none were detected. First aid
was administered. He was removed from the shaft, placed into an
ambulance and transported to the local hospital. He was pronounced
dead at 12:43 p.m., as the result of blunt force injuries and
compression.

Green was not using a safety belt and lanyard during his activities
on the day of the accident. His PM sheets were found on a
clipboard on the ninth floor of the preheater tower near the
elevator's outer shaft door. The sheets indicated that he had
completed a mechanical inspection of pneumatic hammers on the third
floor and a similar inspection of the same items on the sixth and
ninth floors.

The accident occurred when the victim fell onto the passenger
compartment of the elevator which was between the 6th and 7th
floors of the preheater tower. The company had allowed the
practice of by-passing the outer door interlocking safety system by
using welding rods to open the doors, exposing miners to the
elevator shaft. Safety lines were not located on any of the floors
of the plant, nor were there structures on which safety lines or
lanyards could be easily secured.

CONCLUSION

The accident was caused by the practice of allowing miners to by-pass the interlocking outer door safety mechanisms, failure to
require the use of safety lines where known hazards presented a
risk of falling, and failure to assure that structures were
available to secure lines and lanyards to protect the safety of
miners.

VIOLATIONS

Order No. 4662461

Issued at 12:50 p.m., June 25, 1997, under
the provisions of Section 103(k)of the Mine Act:

This order is issued to ensure the safety of miners until a
systematic evaluation of the conditions and safety practices are
conducted, and determination is made that hazards similar to those
that caused or contributed to the accident have been eliminated.
The elevator electrical system and elevator shaft are the only
areas affected where the fatal accident occurred and the victim was
found.

The order was terminated on August 25, 1997.

Citation No. 4652842

Issued under the provisions of Section
104(d)(1) on August 15, 1997, for violation of 30 CFR 56.15005:

A fatal accident occurred on June 25, 1997, when an employee fell
into an open elevator shaft in the preheater tower. The employee
opened an outer elevator shaft door without the passenger
compartment being in position on the floor he was on. The employee
was not wearing a safety belt and line to prevent his falling into
the shaft. Management officials were aware that employees were
regularly accessing the shaft using a welding rod to open the outer
doors. Management's failure to ensure that employees were wearing
safety belts and lines while performing this activity constitutes
more than ordinary negligence. This violation is an unwarrantable
failure.

The citation was terminated on August 22, 1997.

Order No. 4652843

Issued under the provisions of Section
104(d)(1) on August 15, 1997, for violation of 30 CFR 56.18002(a):

A fatal accident occurred on June 25, 1997, when an employee fell
into an open elevator shaft in the preheater tower. Management
officials were aware that employees were regularly exposing
themselves to a fall hazard by using a welding rod to open the
outer shaft doors. The mine operator's examination of workplaces
did not result in or initiate appropriate action to correct this
hazard which affected the safety of employees. The mine operator
engaged in conduct which fell below a standard of care to protect
persons against risk of harm. This violation is an unwarrantable
failure.